Closing Comments

The diagnosis lifelong or acquired PE in daily clinical practice is not difficult and can be achieved with a careful medical and sexual history. Detailed evaluation with questionnaires or stopwatch is not required. Pivotal to the management of PE is the recognition that PE is a condition defined by the IELT and the dimensions of control, satisfaction and bother. Reliance on patient self-report is associated with a high level of false-positive diagnosis of PE, and consequential inappropriate treatment. However, the results of epidemiologic research, research for development of an evidence-based consensus of PE, and drug/psychotherapy treatment research, are only reliable, interpretable and capable of being generalized to patients with the disorder studied when conducted in well-defined and consistent populations, using a double-blind placebo-controlled study design, with consistent objective physiologic measures or sensitive, validated outcome assessment instruments as study endpoints.

The lack of agreement as to what constitutes PE has hampered basic and clinical research into the etiology and management of this condition. A consensus definition of PE should be evidence-based, trans-cultural and applicable in all parts of the world. The recent proposal for a definition of lifelong PE based on the 0.5 and 2.5 percentile of the IELT distribution in the general male population may contribute to a consensus, but more at-random IELT stopwatch studies should be conducted in the various parts of the world.

Although recent neuropharmacologic studies and animal research has deepened our understanding of neurobiology of PE and the mechanism of pharma-cotherapy, a genuine understanding of the etiology of lifelong and acquired premature ejaculation is still lacking. Despite high levels of evidence from multiple well-controlled studies to support the efficacy of drug treatment strategies in lifelong PE, there is little or no evidence to support the role and longitudinal efficacy of behavioral therapy. As such, the place of behavioral therapy must be limited to a supportive role of pharmacotherapy in selected men and not as a first-line treatment. First-line treatment of lifelong PE is off-label daily use of some SSRIs—particularly paroxetine, sertraline and fluoxetine, and clomipramine, and the on-demand use of some SSRIs, clomipramine, and topical anesthetics, although the latter exert less ejaculation-delaying effects. Ejaculation-specific selective serotonin re-uptake inhibitors (ESSRIs), such as dapoxetine, will clearly expand but not dominate or replace our current therapeutic armamentarium. Comparative studies are needed to investigate potential differences between both classes of SSRIs.

An effective treatment of lifelong inhibited ejaculation does not exist. It is therefore ethical to inform men at risk of developing IE secondary to surgery or drug treatment, and to discuss all treatment options for IE, emphasizing the lack of a universal response to psychotherapy.

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